Save & New
Medical Expense Details
| Household Member | |||||||
|---|---|---|---|---|---|---|---|
| Received Date |
| ||||||
| Amount | Frequency | ||||||
| Last Payment Date |
| Medical Expense Type | |||||
| Start Date |
| End Date |
| ||||
| Written Off Amount | Reimbursement Type | ||||||
| Reimbursed Amount |
Medical Service Provider Details
If the medical service provider is a case participant, please select from below.
| |||||
If the medical service provider is not a case participant but is registered on the system, please select from below.
| |||||
If the medical service provider is not registered on the system, complete the medical service provider details below.
| |||||
| |||||
Additional Medical Expense Details
If the Person in Receipt of Service is a case participant, please select from below
| Person in Receipt of Service Participant | |||
|---|---|---|---|
| Living at Home | |||
| Client Obligated Amount | |||
| HMO | TPL | ||
| Medically Necessary | State Provided | ||
| Covered By Medical Assistance | Hold | ||
| Expense Classification |
Medical Expense Payment Details
| Household Member | |||||
|---|---|---|---|---|---|
| Payment Receipt Number | Payment Method | ||||
| Date Paid |
| Amount Paid |
Amount Assigned To Spend Down
| Outstanding Amount | [Amount] | Assigned Amount |
|---|